Stroke: working toward a prioritized world agenda

Melanocortin Derivatives Induced Vascularization and Neuroglial Proliferation in the Rat Brain under Conditions of Cerebral Ischemia

Stroke remains the second leading cause of death worldwide. The development of new therapeutic agents focused on restoring vascular function and neuroprotection of viable tissues is required. In this study the neuroprotective activity of melanocortin-like ACTH(4-7)PGP and ACTH(6-9)PGP peptides was investigated in rat brain at 24 h after transient middle cerebral artery occlusion (tMCAO). The severity of ischemic damage, changes in the proliferative activity of neuroglial cells and vascularization of rat brain tissue were analyzed. The administration of peptides resulted in a significant increase in the volume density of neurons in the perifocal zone of infarction compared to rats subjected to ischemia and receiving saline. Immunohistochemical analysis of the proliferative activity of neuroglia cells using PCNA antibodies showed a significant increase in the number of proliferating cells in the penumbra and in the intact cerebral cortex of rats receiving peptide treatment. The effect of peptides on vascularization was examined using CD31 antibodies under tMCAO conditions, revealing a significant increase in the volume density of vessels and their sizes in the penumbra after administration of ACTH(4-7)PGP and ACTH(6-9)PGP. These findings confirm the neuroprotective effect of peptides due to the activation of neuroglia proliferation and the enhancement of collateral blood flow.

What will it take to achieve brain health globally?

Brain health initiatives and programs are gaining traction worldwide. Some are clinically based, others research based, and some are a combination of clinical and research action plans. Achievement of global brain health is a challenging endeavor with prerequisites including but not limited to multidisciplinary and multisectoral approaches, strengthening of neurologic policies at local and regional levels, global advocacy, leadership and collaboration amongst stakeholders, development of technical and guidance documents, and strengthening and interpretation of the relevant evidence. Over 1 billion persons worldwide are impacted by neurologic disorders, and brain health initiatives are needed to curb the human suffering and cost of these disorders. We provide a brief review of select brain health initiatives and programs and offer possible steps to achieve brain health globally.

Effect of tDCS on corticomuscular coupling and the brain functional network of stroke patients

Transcranial direct current stimulation (tDCS) is an emerging brain intervention technique that has gained growing attention in recent years in the rehabilitation area. In this paper, we investigated the efficacy of tDCS in the rehabilitation process of stroke patients, utilizing corticomuscular coupling (CMC) and brain functional network analysis. Specifically, we examined changes in CMC relationships between the treatment and control groups before and after rehabilitation by transfer entropy (TE), and constructed brain functional networks by TE. We further calculated features of the functional networks, including node degree, global efficiency, clustering coefficient, characteristic path length, and small world index. Our results demonstrate that CMC in patients increased significantly after treatment, with greater improvements in the tDCS group, particularly within the beta and gamma bands. In addition, the functional brain network analysis revealed enhanced connectivity between brain regions, improved information processing capacity, and increased transmission efficiency in patients as their condition improved. Notably, treatment with tDCS resulted in more significant improvements than the sham group, with a statistically significant difference observed after rehabilitation treatment (p < 0.05). These findings provide compelling evidence regarding the role of tDCS in the treatment of stroke and highlight the potential of this approach in stroke rehabilitation. The use of tDCS for therapeutic interventions in stroke rehabilitation can significantly improve the coupling of patients' functional brain networks. Also, using Transfer Entropy (TE) as a characteristic of CMC, tDCS was found to significantly enhance patients' TE, i.e. enhanced CMC.

A novel specific aptamer targets cerebrovascular endothelial cells after ischemic stroke

Cell specific-targeted therapy (CSTT) for acute ischemic stroke remains underdeveloped. Cerebrovascular endothelial cells (CECs) are key components of the blood-brain barrier and are the first brain cells affected by ischemic stroke. After stroke, CEC injury causes insufficient energy supply to neurons and leads to cytotoxic and vasogenic brain edema. Aptamers are short single-stranded RNA or DNA molecules that can bind to specific ligands for cell specific delivery. The expression of vascular cell adhesion molecule-1 (VCAM-1) is increased on CECs after stroke. Herein, we report that an RNA-based VCAM-1-aptamer can specifically target CECs in stroke brains following transient middle cerebral artery occlusion in mice. Our data demonstrate the potential of an RNA-based aptamer as an effective delivery platform to target CECs after stroke. We believe this method will allow for the development of CSTT for treatment of patients with stroke.

An Integrated Machine Learning-Based Brain Computer Interface to Classify Diverse Limb Motor Tasks: Explainable Model

Terminal neurological conditions can affect millions of people worldwide and hinder them from doing their daily tasks and movements normally. Brain computer interface (BCI) is the best hope for many individuals with motor deficiencies. It will help many patients interact with the outside world and handle their daily tasks without assistance. Therefore, machine learning-based BCI systems have emerged as non-invasive techniques for reading out signals from the brain and interpreting them into commands to help those people to perform diverse limb motor tasks. This paper proposes an innovative and improved machine learning-based BCI system that analyzes EEG signals obtained from motor imagery to distinguish among various limb motor tasks based on BCI competition III dataset IVa. The proposed framework pipeline for EEG signal processing performs the following major steps. The first step uses a meta-heuristic optimization technique, called the whale optimization algorithm (WOA), to select the optimal features for discriminating between neural activity patterns. The pipeline then uses machine learning models such as LDA, k-NN, DT, RF, and LR to analyze the chosen features to enhance the precision of EEG signal analysis. The proposed BCI system, which merges the WOA as a feature selection method and the optimized k-NN classification model, demonstrated an overall accuracy of 98.6%, outperforming other machine learning models and previous techniques on the BCI competition III dataset IVa. Additionally, the EEG feature contribution in the ML classification model is reported using Explainable AI (XAI) tools, which provide insights into the individual contributions of the features in the predictions made by the model. By incorporating XAI techniques, the results of this study offer greater transparency and understanding of the relationship between the EEG features and the model's predictions. The proposed method shows potential levels for better use in controlling diverse limb motor tasks to help people with limb impairments and support them while enhancing their quality of life.

The Role of the lncRNA MALAT1 in Neuroprotection against Hypoxic/Ischemic Injury

Hypoxic and ischemic brain injury can cause neurological disability and mortality, and has become a serious public health problem worldwide. Long-chain non-coding RNAs are involved in the regulation of many diseases. Metastasis-related lung adenocarcinoma transcript 1 (MALAT1) is a type of long non-coding RNA (lncRNA), known as long intergenic non-coding RNA (lincRNA), and is highly abundant in the nervous system. The enrichment of MALAT1 in the brain indicates that it may be associated with important functions in pathophysiological processes. Accordingly, the role of MALAT1 in neuronal cell hypoxic/ischemic injury has been gradually discovered over recent years. In this article, we summarize recent research regarding the neuroprotective molecular mechanism of MALAT1 and its regulation of pathophysiological processes of brain hypoxic/ischemic injury. MALAT1 may function as a regulator through interaction with proteins or RNAs to perform its role, and may therefore serve as a therapeutic target in cerebral hypoxia/ischemia.

Primary stroke prevention worldwide: translating evidence into action

Stroke is the second leading cause of death and the third leading cause of disability worldwide and its burden is increasing rapidly in low-income and middle-income countries, many of which are unable to face the challenges it imposes. In this Health Policy paper on primary stroke prevention, we provide an overview of the current situation regarding primary prevention services, estimate the cost of stroke and stroke prevention, and identify deficiencies in existing guidelines and gaps in primary prevention. We also offer a set of pragmatic solutions for implementation of primary stroke prevention, with an emphasis on the role of governments and population-wide strategies, including task-shifting and sharing and health system re-engineering. Implementation of primary stroke prevention involves patients, health professionals, funders, policy makers, implementation partners, and the entire population along the life course.

Existence of knowledge silos in the adult blunt cerebrovascular injury literature

Background

Blunt cerebrovascular injuries (BCVI) remain a significant source of disability and mortality among trauma patients. The purpose of the present study was to determine whether knowledge silos exist in the overall BCVI literature.

Methods

An object-oriented programmatic script written in Python programming language was used to extract and categorize articles and references on the topic of BCVI. Additionally, each BCVI article was searched for by digital object identifier in the other BCVI references to build a network analysis and visualize topic reference patterns. Analyses were performed using Stata V.14.2 (StataCorp).

Results

A total of 306 articles with 10 282 references were included for analysis. Of these, 24% (74) were published in neurosurgery journals, 45% (137) were published in trauma journals, and 31% (95) were published in a journal of another specialty. Similar proportions were found when categorized by author departmental affiliation. Trauma surgery authors disproportionately referenced articles in the trauma literature, compared with neurosurgeons (73.5% vs. 48.0%, p<0.0001), and other authors. The biggest factor influencing reference proportions was the specialty of the publishing journal. Finally, a network analysis revealed that there are more trauma BCVI articles, and there are more frequently cited trauma BCVI articles by all specialties.

Conclusions

This study revealed the existence of a one-way knowledge silo in the BCVI literature. However, a robust preference by both trauma and neurosurgery to cite trauma references when publishing in trauma journals may indicate a possible conscious curating of citations by authors to increase the likelihood of publication. These observations highlight the need for an active role by journal editors, peer reviewers, and authors to actively foster diversity of citations and cross-specialty collaboration to improve dissemination of information between these specialties.

Level of evidence

Level IV. Observational study.

Tyrosol as a Neuroprotector: Strong Effects of a "Weak" Antioxidant

The use of neuroprotective agents for stroke is pathogenetically justified, but the translation of the results of preclinical studies of neuroprotectors into clinical practice has been a noticeable failure. One of the leading reasons for these failures is the one-target mechanism of their activity. p-Tyrosol (Tyr), a biophenol, is present in a variety of natural sources, mainly in foods, such as olive oil and wine. Tyr has a wide spectrum of biological activity: antioxidant, stress-protective, anti-inflammatory, anticancer, cardioprotective, neuroprotective and many others. This review analyzes data on the neuroprotective, antioxidant, anti-inflammatory, anti-apoptotic and other kinds of Tyr activity as well as data on the pharmacokinetics of the substance. The data presented in the review substantiate the acceptability of tyr as the basis for the development of a new neuroprotective drug with multitarget activity for the treatment of ischemic stroke. Tyr is a promising molecule for the development of an effective neuroprotective agent for use in ischemic stroke.

Brain Computer Interface Treatment for Motor Rehabilitation of Upper Extremity of Stroke Patients-A Feasibility Study

Introduction

Numerous recent publications have explored Brain Computer Interfaces (BCI) systems as rehabilitation tools to help subacute and chronic stroke patients recover upper extremity movement. Recent work has shown that BCI therapy can lead to better outcomes than conventional therapy. BCI combined with other techniques such as Functional Electrical Stimulation (FES) and Virtual Reality (VR) allows to the user restore the neurological function by inducing the neural plasticity through improved real-time detection of motor imagery (MI) as patients perform therapy tasks.

Methods

Fifty-one stroke patients with upper extremity hemiparesis were recruited for this study. All participants performed 25 sessions with the MI BCI and assessment visits to track the functional changes before and after the therapy.

Results

The results of this study demonstrated a significant increase in the motor function of the paretic arm assessed by Fugl-Meyer Assessment (FMA-UE), ΔFMA-UE = 4.68 points, P < 0.001, reduction of the spasticity in the wrist and fingers assessed by Modified Ashworth Scale (MAS), ΔMAS-wrist = -0.72 points (SD = 0.83), P < 0.001, ΔMAS-fingers = -0.63 points (SD = 0.82), P < 0.001. Other significant improvements in the grasp ability were detected in the healthy hand. All these functional improvements achieved during the BCI therapy persisted 6 months after the therapy ended. Results also showed that patients with Motor Imagery accuracy (MI) above 80% increase 3.16 points more in the FMA than patients below this threshold (95% CI; [1.47–6.62], P = 0.003). The functional improvement was not related with the stroke severity or with the stroke stage.

Conclusion

The BCI treatment used here was effective in promoting long lasting functional improvements in the upper extremity in stroke survivors with severe, moderate and mild impairment. This functional improvement can be explained by improved neuroplasticity in the central nervous system.

Prediction of Recovery and Outcome Using Motor Evoked Potentials and Brain Derived Neurotrophic Factor in Subacute Stroke

INTRODUCTION AND OBJECTIVES

Motor evoked potentials (MEPs) have been postulated to be useful in predicting recovery in patients with motor impairment. We aimed to investigate whether MEPs elicited by transcranial magnetic stimulation (TMS), serum brain derived neurotrophic factor (BDNF) and its genotype have prognostic value on stroke recovery in patients with hand paresis due to stroke.

METHODS

This was an observational cohort study. Patients underwent TMS with MEPs from abductor digiti minimi evaluation between 2-14 (D0) and 30 days (D30) after stroke and their impact on motor function of the upper limb and general outcome was assessed after 3 months (D90). The presence of a BDNF gene polymorphism was determined and serum BDNF concentrations were measured at D0, D30 and D90.

RESULTS

The presence of MEPs and their amplitude at rest and in effort significantly correlated with improvement of upper-limb paresis and general outcome after 3 months. Resting motor threshold did not have prognostic value. Central motor conduction time and MEP latency less consistently predicted stroke outcome or motor deficit improvement. Neither BDNF polymorphisms nor BDNF concentration at D0, D30 and D90 corresponded with the degree of paresis or the independence of patients 3 months after stroke.

CONCLUSIONS

The presence of MEPs and their amplitude are useful predictors of upper-limb motor function recovery and general outcome after stroke. BDNF concentration and its genotype had no prognostic value. Further studies conducted on large cohorts are necessary to determine the usefulness of these methods in motor recovery and stroke outcome prediction.

Innovative Long-Dose Neurorehabilitation for Balance and Mobility in Chronic Stroke: A Preliminary Case Series

(1) Objective: The objective was two-fold: (a) test a protocol of combined interventions; (b) administer this combined protocol within the framework of a six-month, intensive, long-duration program. The array of interventions was designed to target the treatment-resistant impairments underlying persistent mobility dysfunction: weakness, balance deficit, limb movement dyscoordination, and gait dyscoordination. (2) Methods: A convenience sample of eight chronic stroke survivors (>4 months post stroke) was enrolled. Treatment was 5 days/week, 1-2.5 h/day for 6 months, as follows: strengthening exercise, balance training, limb/gait coordination training, and aerobic exercise. Outcome measures: Berg Balance Scale (BBS), Fugl-Meyer Lower Limb Coordination (FM), gait speed, 6 Minute Walk Test (6MWT), Timed up and Go (TUG), Functional Independence Measure (FIM), Craig Handicap Assessment Rating Tool (CHART), and personal milestones. Pre-/post-treatment comparisons were conducted using the Permutation Test, suitable for ordinal measures and small sample size. (3) Results: For the group, there was a statistically (p ≤ 0.04) significant improvement in balance, limb movement coordination (FM), gait speed, functional mobility (TUG), and functional activities (FIM). There were measurable differences (minimum detectible change: MDC) in BBS, FM, gait speed, 6MWT, and TUG. There were clinically significant milestones achieved for selected subjects according to clinical benchmarks for the BBS, 6MWT, gait speed, and TUG, as well as achievement of personal milestones of life role participation. Effect sizes (Cohen's D) ranged from 0.5 to 1.0 (with the exception of the (6MWT)). After six months of treatment, the above array of gains were beyond that reported by other published studies of chronic stroke survivor interventions. Personal milestones included: walking to mailbox, gardening/yardwork, walking a distance to neighbors, return to driving, membership at a fitness center, vacation trip to the beach, swimming at local pool, returning to work, housework, cooking meals. (4) Conclusions: Stroke survivors with mobility dysfunction were able to participate in the long-duration, intensive program, with the intervention array targeted to address impairments underlying mobility dysfunction. There were either clinically or statistically significant improvements in an array of measures of impairment, functional mobility, and personal milestone achievements.

Conceptual framework for establishing the African Stroke Organization

Africa is the world's most genetically diverse, second largest, and second most populous continent, with over one billion people distributed across 54 countries. With a 23% lifetime risk of stroke, Africa has some of the highest rates of stroke worldwide and many occur in the prime of life with huge economic losses and grave implications for the individual, family, and the society in terms of mental capital, productivity, and socioeconomic progress. Tackling the escalating burden of stroke in Africa requires prioritized, multipronged, and inter-sectoral strategies tailored to the unique African epidemiological, cultural, socioeconomic, and lifestyle landscape. The African Stroke Organization (ASO) is a new pan-African coalition that brings together stroke researchers, clinicians, and other health-care professionals with participation of national and regional stroke societies and stroke support organizations. With a vision to reduce the rapidly increasing burden of stroke in Africa, the ASO has a four-pronged focus on (1) research, (2) capacity building, (3) development of stroke services, and (4) collaboration with all stakeholders. This will be delivered through advocacy, awareness, and empowerment initiatives to bring about people-focused changes in policy, clinical practice, and public education. In the spirit of the African philosophy of Ubuntu "I am because we are," the ASO will harness the power of diversity, inclusiveness, togetherness, and team work to build a strong, enduring, and impactful platform for tackling stroke in Africa.

Establishment of an internationally agreed minimum data set for acute telestroke

INTRODUCTION

Globally, the use of telestroke programmes for acute care is expanding. Currently, a standardised set of variables for enabling reliable international comparisons of telestroke programmes does not exist. The aim of the study was to establish a consensus-based, minimum dataset for acute telestroke to enable the reliable comparison of programmes, clinical management and patient outcomes.

METHODS

An initial scoping review of variables was conducted, supplemented by reaching out to colleagues leading some of these programmes in different countries. An international expert panel of clinicians, researchers and managers (n = 20) from the Australasia Pacific region, USA, UK and Europe was convened. A modified-Delphi technique was used to achieve consensus via online questionnaires, teleconferences and email.

RESULTS

Overall, 533 variables were initially identified and harmonised into 159 variables for the expert panel to review. The final dataset included 110 variables covering three themes (service configuration, consultations, patient information) and 12 categories: (1) details about telestroke network/programme (n = 12), (2) details about initiating hospital (n = 10), (3) telestroke consultation (n = 17), (4) patient characteristics (n = 7), (5) presentation to hospital (n = 5), (6) general clinical care within first 24 hours (n = 10), (7) thrombolysis treatment (n = 10), (8) endovascular treatment (n = 13), (9) neurosurgery treatment (n = 8), (10) processes of care beyond 24 hours (n = 7), (11) discharge information (n = 5), (12) post-discharge and follow-up data (n = 6).

DISCUSSION

The acute telestroke minimum dataset provides a recommended set of variables to systematically evaluate acute telestroke programmes in different countries. Adoption is recommended for new and existing services.

Prognostic and Monitory EEG-Biomarkers for BCI Upper-Limb Stroke Rehabilitation

With the availability of multiple rehabilitative interventions, identifying the one that elicits the best motor outcome based on the unique neuro-clinical profile of the stroke survivor is a challenging task. Predicting the potential of recovery using biomarkers specific to an intervention hence becomes important. To address this, we investigate intervention-specific prognostic and monitory biomarkers of motor function improvements using quantitative electroencephalography (QEEG) features in 19 chronic stroke patients following two different upper extremity rehabilitative interventions viz. Brain-computer interface (BCI) and transcranial direct current stimulation coupled BCI (tDCS-BCI). Brain symmetry index was found to be the best prognostic QEEG for clinical gains following BCI intervention ( r = -0.80 , p = 0.02 ), whereas power ratio index (PRI) was observed to be the best predictor for tDCS-BCI ( r = -0.96 , p = 0.004 ) intervention. Importantly, statistically significant between-intervention differences observed in the predictive capabilities of these features suggest that intervention-specific biomarkers can be identified. This approach can be further pursued to distinctly predict the expected response of a patient to available interventions. The intervention with the highest predicted gains may then be recommended to the patient, thereby enabling a personalized rehabilitation regime.

A roadmap for promoting endogenous in situ tissue restoration using inductive bioscaffolds after acute brain injury

The regeneration of brain tissue remains one of the greatest unsolved challenges in medicine and by many is considered unfeasible. Indeed, the adult mammalian brain does not regenerate tissue, but there is ongoing endogenous neurogenesis, which is upregulated after injury and contributes to tissue repair. This endogenous repair response is a conditio sine que non for tissue regeneration. However, scarring around the lesion core and cavitation provide unfavorable conditions for tissue regeneration in the brain. Based on the success of using extracellular matrix (ECM)-based bioscaffolds in peripheral soft tissue regeneration, it is plausible that the provision of an inductive ECM-based hydrogel inside the volumetric tissue loss can attract neural cells and create a de novo viable tissue. Following perturbation theory of these successes in peripheral tissues, we here propose 9 perturbation parts (i.e. requirements) that can be solved independently to create an integrated series to build a functional and integrated de novo neural tissue. Necessities for tissue formation, anatomical and functional connectivity are further discussed to provide a new substrate to support the improvement of behavioral impairments after acute brain injury. We also consider potential parallel developments of this tissue engineering effort that can support therapeutic benefits in the absence of de novo tissue formation (e.g. structural support to veterate brain tissue). It is envisaged that eventually top-down inductive "natural" bioscaffolds composed of decellularized tissues (i.e. ECM) will be replaced by bottom-up synthetic designer hydrogels that will provide very defined structural and signaling properties, potentially even opening up opportunities we currently do not envisage using natural materials.

Comparative efficacy and safety of cognitive enhancers for treating vascular cognitive impairment: systematic review and Bayesian network meta-analysis

Objective

To assess and compare the clinical efficacy and safety of cognitive enhancers (donepezil, galantamine, rivastigmine, and memantine) on cognition, behavior, function, and global status in patients with vascular cognitive impairment.

Data sources

The initial literature search was performed with PubMed, EMBASE, the Cochrane Methodology Register, the Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing & Allied Health (CINAHL) from inception to January 2018 for studies regarding donepezil, galantamine, rivastigmine, and memantine for treatment of vascular cognitive impairment.

Data selection

Randomized controlled trials on donepezil, galantamine, rivastigmine, and memantine as monotherapy in the treatment of vascular cognitive impairment were included. A Bayesian network meta-analysis was conducted.

Outcome measures

Efficacy was assessed by changes in scores of the Alzheimer's Disease Assessment Scale, cognitive subscale, Mini-Mental State Examination, Neuropsychiatric Inventory scores and Clinician's Interview-Based Impression of Change Scale Plus Caregiver's Input, Activities of Daily Living, the Clinical Dementia Rating scale. Safety was evaluated by mortality, total adverse events (TAEs), serious adverse events (SAEs), nausea, vomiting. diarrhea, or cerebrovascular accidents (CVAs).

Results

After screening 1717 citations, 12 randomized controlled trials were included. Donepezil and rivastigmine (mean difference (e) = -0.77, 95% confidence interval (CI): 0.25-1.32; MD = 1.05, 95% CI: 0.18-1.79) were significantly more effective than placebo in reducing Mini-Mental State Examination scores. Donepezil, galantamine, and memantine (MD = -1.30, 95% CI: -2.27 to -0.42; MD = -1.67, 95% CI: -3.36 to -0.06; MD = -2.27, 95% CI: -3.91 to -0.53) showed superior benefits on the Alzheimer's Disease Assessment Scale-cognitive scores compared with placebo. Memantine (MD = 2.71, 95% CI: 1.05-7.29) improved global status (Clinician's Interview-Based Impression of Change Scale Plus Caregiver's Input) more than the placebo. Safety results revealed that donepezil 10 mg (odds ratio (OR) = 3.04, 95% CI: 1.86-5.41) contributed to higer risk of adverse events than placebo. Galantamine (OR = 5.64, 95% CI: 1.31-26.71) increased the risk of nausea. Rivastigmine (OR = 16.80, 95% CI: 1.78-319.26) increased the risk of vomiting. No agents displayed a significant risk of serious adverse events, mortality, cerebrovascular accidents, or diarrhea.

Conclusion

We found significant efficacy of donepezil, galantamine, and memantine on cognition. Memantine can provide significant efficacy in global status. They are all safe and well tolerated.

Study on the mechanism of JAK2/STAT3 signaling pathway-mediated inflammatory reaction after cerebral ischemia

The present study aimed to investigate the mechanism by which the Janus kinase (JAK)2/signal transducer and activator of transcription (STAT)3 signaling pathway mediates cerebral ischemia and the efficacy of pharmaceutical intervention. The rat model of middle cerebral artery occlusion (MCAO) was established and confirmed via assessment of changes in the expression of phosphorylated (p)‑JAK2, p‑STAT3, high‑mobility group box 1 (HMGB1), and inflammatory factors using ELISA and western blot analysis. The effects of JAK2/STAT3 inhibitor and curcumin on the expression of p‑JAK2, p‑STAT3, HMGB1, and inflammatory factors after cerebral ischemia were observed with ELISA, western blotting and immunohistochemical staining. The concentrations of tumor necrosis factor (TNF)‑α and HMGB1 in brain tissue homogenate of MCAO group were significantly higher than in the sham group (P<0.01). The concentration of p‑JAK2/JAK2 and p‑STAT3/STAT3 in the brain tissue homogenate of MCAO group was significantly higher than in the sham group (P<0.05). The concentrations of TNF‑α, interleukin (IL)‑1β, IL‑6, and HMGB1 in the group treated with STAT3 inhibitor (MCAO + rapamycin), JAK2 inhibitor (MCAO + AG490), and MCAO + curcumin were significantly lower than in the MCAO group (P<0.01), as well as the relative content of p‑JAK2/JAK2 and p‑STAT3/STAT3 (P<0.05). Inhibition of the JAK2/STAT3 signaling pathway, such as curcumin can reduce the expression of HMGB1 in brain tissue after cerebral ischemia, which can significantly reduce the inflammatory response after cerebral ischemia.

Needs and rights awareness of stroke survivors and caregivers: a cross-sectional, single-centre questionnaire survey

OBJECTIVES

The needs and rights awareness of stroke survivors have not been reported in China. This study investigated the needs and rights awareness of stroke survivors and caregivers in Tianjin, China.

SETTING

A survey launched by the World Stroke Organization was conducted in Tianjin, China. The questionnaire included demands for psychological support, treatment and care, social support and information. Stroke survivors and their caregivers were interviewed face to face for the questionnaire. Between June 2014 and February 2015, stroke survivors were invited to participate if they were more than 18 years old and had experienced a stroke. Exclusion criteria were patients who had disorders of consciousness, significant cognitive impairment, aphasia, communication difficulties or psychiatric disorders. Only caregivers who were family members of the patients were chosen. Paid caregivers were excluded.

PARTICIPANTS

Two hundred and forty-eight stroke survivors and 212 caregivers were enrolled.

PRIMARY OUTCOME MEASURES

The correlations between levels of needs and potential effect factors were analysed. Levels of different needs were compared by age, gender and time since stroke.

RESULTS

Among the cohort, 95.6% stroke survivors and 92.5% caregivers agreed to each question in the questionnaire. The participants prioritised the needs for psychological support (99.4%), treatment and care (98.6%), social support (98%) and information (96.2%). The total score was negatively correlated with age (r=-0.255, p<0.01). Patients below 65 years old had higher scores than those 65 years or older (p<0.01), while male patients had higher scores than female patients (p<0.01).

CONCLUSIONS

The needs for psychological and emotional support, individual treatment, social support and information about stroke were eagerly reported by most survivors. The Bill of Rights must be recognised by the Chinese society, providing appropriate stroke care to every patient to optimise stroke outcomes.

Inhibition of cerebral ischemia/reperfusion injury-induced apoptosis: nicotiflorin and JAK2/STAT3 pathway

Nicotiflorin is a flavonoid extracted from Carthamus tinctorius. Previous studies have shown its cerebral protective effect, but the mechanism is undefined. In this study, we aimed to determine whether nicotiflorin protects against cerebral ischemia/reperfusion injury-induced apoptosis through the JAK2/STAT3 pathway. The cerebral ischemia/reperfusion injury model was established by middle cerebral artery occlusion/reperfusion. Nicotiflorin (10 mg/kg) was administered by tail vein injection. Cell apoptosis in the ischemic cerebral cortex was examined by hematoxylin-eosin staining and terminal deoxynucleotidyl transferase dUTP nick end labeling assay. Bcl-2 and Bax expression levels in ischemic cerebral cortex were examined by immunohistochemial staining. Additionally, p-JAK2, p-STAT3, Bcl-2, Bax, and caspase-3 levels in ischemic cerebral cortex were examined by western blot assay. Nicotiflorin altered the shape and structure of injured neurons, decreased the number of apoptotic cells, down-regulates expression of p-JAK2, p-STAT3, caspase-3, and Bax, decreased Bax immunoredactivity, and increased Bcl-2 protein expression and immunoreactivity. These results suggest that nicotiflorin protects against cerebral ischemia/reperfusion injury-induced apoptosis via the JAK2/STAT3 pathway.

Safety and efficacy of minimally invasive surgery plus alteplase in intracerebral haemorrhage evacuation (MISTIE): a randomised, controlled, open-label, phase 2 trial

Background

Craniotomy, when evaluated in trials, does not improve outcome after intracerebral haemorrhage (ICH). Whether minimally invasive catheter evacuation followed by thrombolysis is safe and can achieve a good functional outcome by removing clot is unknown. We investigated safety and efficacy of alteplase with minimally invasive surgery (MIS) in patients with intracerebral haemorrhage.

Methods

MISTIE was an international, randomized, open-label study and was done in 26 hospitals in the USA, Canada, the UK, and Germany. Patients (aged 18–80 years), with non-traumatic (spontaneous) ICH ≥20 mL were randomly allocated, centrally, to medical care or image-guided MIS plus rt-PA (0.3 mg or 1.0 mg every 8 hours for up to 9 doses) to remove clot using surgical aspiration followed with alteplase clot irrigation. The primary efficacy outcome was the adjusted dichotomized modified Rankin Scale (mRS) 0–3 vs 4–6 assessed at day 180 after symptom onset. Analysis was by intention to treat. (ClinicalTrials.gov number NCT00224770).

Findings

Between February 2, 2006 and April 8, 2013, 96 subjects were randomized and completed follow-up: 54 received treatment and 42 medical care. Primary safety outcomes: mortality, symptomatic bleeding, brain infections, as well as withdrawal of care, did not differ between groups. Asymptomatic hemorrhages were more common in the surgical group (3 (7%) vs. 12 (22%) p= 0.05) producing a difference of 15.1% (95% CI: 1.5% to 28.6%). The estimated absolute benefit, i.e., the unadjusted difference in observed proportions of all subjects with mRS 0–3 (33% vs 21%) at 180 days comparing MISPA vs. medical control, is 0.109 [95%CI: −0.088, 0.294; p=0.26], and is 0.162 [95%CI: 0.003, 0.323; p=0.05] after adjustment for potential imbalances in baseline severity between study arms (primary efficacy outcome).

Interpretation

MIS+rt-PA appears safe with an apparent advantage of better functional outcome at 180 days. Increased asymptomatic bleeding is a major cautionary finding. The MISTIE trial results, if replicable, could produce a meaningful functional benefit adding surgical management as a therapeutic strategy for ICH.

Funding

National Institute of Neurologic Disorders and Stroke, Genentech, and Codman.

Transcranial magnetic stimulation (TMS) in stroke: Ready for clinical practice?

The use of transcranial magnetic stimulation (TMS) in stroke research has increased dramatically over the last decade with two emerging and potentially useful functions identified. Firstly, the use of single pulse TMS as a tool for predicting recovery of motor function after stroke, and secondly, the use of repetitive TMS (rTMS) as a treatment adjunct aimed at modifying the excitability of the motor cortex in preparation for rehabilitation. This review discusses recent advances in the use of TMS in both prediction and treatment after stroke. Prediction of recovery after stroke is a complex process and the use of TMS alone is not sufficient to provide accurate prediction for an individual after stroke. However, when applied in conjunction with other tools such as clinical assessment and MRI, accuracy of prediction using TMS is increased. rTMS temporarily modulates cortical excitability after stroke. Very few rTMS studies are completed in the acute or sub-acute stages after stroke and the translation of altered cortical excitability into gains in motor function are modest, with little evidence of long term effects. Although gains have been made in both of these areas, further investigation is needed before these techniques can be applied in routine clinical care.

'TIDieR-ing up' the reporting of interventions in stroke research: the importance of knowing what is in the 'black box'

Evidence-based interventions cannot be provided unless there is a clear understanding of what the intervention is. Many published randomized trials, systematic reviews, and guidelines contain incomplete intervention descriptions. For non-pharmacological interventions, such as stroke rehabilitation, the reporting is particularly poor. Contributors to this problem include lack of attention to this issue and awareness of what constitutes a complete intervention description by authors, reviewers, journals, and editors. Part of the solution is for authors to follow guidance about how to describe interventions, such as the Template for Intervention Description and Replication statement. Improving stroke interventions reporting will remove one of the current barriers to evidence-based care.

National stroke registries for monitoring and improving the quality of hospital care: A systematic review

Background

Routine monitoring of the quality of stroke care is becoming increasingly important since patient outcomes could be improved with better access to proven treatments. It remains unclear how many countries have established a national registry for monitoring stroke care.

Aims

To describe the current status of national, hospital-based stroke registries that have a focus on monitoring access to evidence-based care and patient outcomes and to summarize the main features of these registries.

Summary of review

We undertook a systematic search of the published literature to identify the registries that are considered in their country to represent a national standardized dataset for acute stroke care and outcomes. Our initial keyword search yielded 5002 potential papers, of which we included 316 publications representing 28 national stroke registries from 26 countries. Where reported, data were most commonly collected with a waiver of patient consent (70%). Most registries used web-based systems for data collection (57%) and 25% used data linkage. Few variables were measured consistently among the registries reflecting their different local priorities. Funding, resource requirements, and coverage also varied.

Conclusions

This review provides an overview of the current use of national stroke registries, a description of their common features relevant to monitoring stroke care in hospitals. Formal registration and description of registries would facilitate better awareness of efforts in this field.

Sex Disparities in Access to Acute Stroke Care: Can Telemedicine Mitigate this Effect?

BACKGROUND

Women have more frequent and severe ischemic strokes than men, and are less likely to receive treatment for acute stroke. Primary stroke centers (PSCs) have been shown to utilize treatment more frequently. Further, as telemedicine (TM) has expanded access to acute stroke care we sought to investigate the association between PSC, TM and access to acute stroke care in the state of Texas.

METHODS

Texas hospitals and resources were identified from the 2009 American Hospital Association Annual Survey. Hospitals were categorized as: (1) stand-alone PSCs not using telemedicine for acute stroke care, (2) PSCs using telemedicine for acute stroke care (PSC-TM), (3) non-PSC hospitals using telemedicine for acute stroke care, or (4) non-PSC hospitals not using telemedicine for acute stroke care. The proportion of the population who could reach a PSC within 60 minutes was determined for stand-alone PSCs, PSC-TM, and non-PSCs using TM for stroke care.

RESULTS

Overall, women were as likely to have 60-minute access to a PSC or PSC-TM as their male counterparts (POR 1.02, 95% CI 1.02-1.03). Women were also just as likely to have access to acute stroke care via PSC or PSC-TM or TM as men (POR 1.03, 95% CI 1.02-1.04).

DISCUSSION

Our study found no sex disparities in access to stand alone PSCs or to hospitals using TM in the state of Texas. The results of this study suggest that telemedicine can be used as part of an inclusive strategy to improve access to care equally for men and women.

What's in a name? The challenge of describing interventions in systematic reviews: analysis of a random sample of reviews of non-pharmacological stroke interventions

OBJECTIVE

To assess, in a sample of systematic reviews of non-pharmacological interventions, the completeness of intervention reporting, identify the most frequently missing elements, and assess review authors' use of and beliefs about providing intervention information.

DESIGN

Analysis of a random sample of systematic reviews of non-pharmacological stroke interventions; online survey of review authors.

DATA SOURCES AND STUDY SELECTION

The Cochrane Library and PubMed were searched for potentially eligible systematic reviews and a random sample of these assessed for eligibility until 60 (30 Cochrane, 30 non-Cochrane) eligible reviews were identified.

DATA COLLECTION

In each review, the completeness of the intervention description in each eligible trial (n=568) was assessed by 2 independent raters using the Template for Intervention Description and Replication (TIDieR) checklist. All review authors (n=46) were invited to complete a survey.

RESULTS

Most reviews were missing intervention information for the majority of items. The most incompletely described items were: modifications, fidelity, materials, procedure and tailoring (missing from all interventions in 97%, 90%, 88%, 83% and 83% of reviews, respectively). Items that scored better, but were still incomplete for the majority of reviews, were: 'when and how much' (in 31% of reviews, adequate for all trials; in 57% of reviews, adequate for some trials); intervention mode (in 22% of reviews, adequate for all trials; in 38%, adequate for some trials); and location (in 19% of reviews, adequate for all trials). Of the 33 (71%) authors who responded, 58% reported having further intervention information but not including it, and 70% tried to obtain information.

CONCLUSIONS

Most focus on intervention reporting has been directed at trials. Poor intervention reporting in stroke systematic reviews is prevalent, compounded by poor trial reporting. Without adequate intervention descriptions, the conduct, usability and interpretation of reviews are restricted and therefore, require action by trialists, systematic reviewers, peer reviewers and editors.

A Neurologist's Guide to TNF Biology and to the Principles behind the Therapeutic Removal of Excess TNF in Disease

Tumor necrosis factor (TNF) is an ancient and widespread cytokine required in small amounts for much physiological function. Higher concentrations are central to innate immunity, but if unchecked this cytokine orchestrates much chronic and acute disease, both infectious and noninfectious. While being a major proinflammatory cytokine, it also controls homeostasis and plasticity in physiological circumstances. For the last decade or so these principles have been shown to apply to the central nervous system as well as the rest of the body. Nevertheless, whereas this approach has been a major success in treating noncerebral disease, its investigation and potential widespread adoption in chronic neurological conditions has inexplicably stalled since the first open trial almost a decade ago. While neuroscience is closely involved with this approach, clinical neurology appears to be reticent in engaging with what it offers patients. Unfortunately, the basic biology of TNF and its relevance to disease is largely outside the traditions of neurology. The purpose of this review is to facilitate lowering communication barriers between the traditional anatomically based medical specialties through recognition of shared disease mechanisms and thus advance the prospects of a large group of patients with neurodegenerative conditions for whom at present little can be done.

MCP-induced protein 1 mediates the minocycline-induced neuroprotection against cerebral ischemia/reperfusion injury in vitro and in vivo

BACKGROUND

Minocycline, a broad-spectrum tetracycline antibiotic, has shown anti-inflammatory and neuroprotective effects in ischemic brain injury. The present study seeks to determine whether monocyte chemotactic protein-induced protein 1 (MCPIP1), a recently identified modulator of inflammatory reactions, is involved in the cerebral neuroprotection conferred by minocycline treatment in the animal model of focal cerebral ischemia and to elucidate the mechanisms of minocycline-induced ischemic brain tolerance.

METHODS

Focal cerebral ischemia was induced by middle cerebral artery occlusion (MCAO) for 2 h in male C57BL/6 mice and MCPIP1 knockout mice followed by 24- or 48-h reperfusion. Twelve hours before ischemia or 2 h after MCAO, mice were injected intraperitoneally with 90 mg/kg of minocycline hydrochloride. Thereafter, the animals were injected twice a day, at a dose of 90 mg/kg after ischemia until sacrificed. Transcription and expression of MCPIP1 gene was monitored by quantitative real-time PCR (qRT-PCR), Western blot, and immunohistochemistry. The neurobehavioral scores, infarction volumes, and proinflammatory cytokines in brain and NF-κB signaling were evaluated after ischemia/reperfusion.

RESULTS

MCPIP1 protein and mRNA levels significantly increased in mouse brain undergoing minocycline pretreatment. Minocycline treatment significantly attenuated the infarct volume, neurological deficits, and upregulation of proinflammatory cytokines in the brain of wild type mice after MCAO. MCPIP1-deficient mice failed to evoke minocycline-treatment-induced tolerance compared with that of the control MCPIP1-deficient group without minocycline treatment. Similarly, in vitro data showed that minocycline significantly induced the expression of MCPIP1 in primary neuron-glial cells, cortical neurons, and reduced oxygen glucose deprivation (OGD)-induced cell death. The absence of MCPIP1 blocked minocycline-induced protection on neuron-glial cells and cortical neurons treated with OGD.

CONCLUSIONS

Our in vitro and in vivo studies demonstrate that MCPIP1 is an important mediator of minocycline-induced protection from brain ischemia.

The effect of propofol postconditioning on the expression of K(+)-Cl(-)-co-transporter 2 in GABAergic inhibitory interneurons of acute ischemia/reperfusion injury rats

It has been shown in our previous study that propofol postconditioning enhanced the activity of phosphatidylinositol-3-kinase (PI3K) and prevented the internalization of GluR2 subunit of α-amino-3-hydroxyl-5-methyl-4-isoxazolepropionic acid (AMPA) receptors, thus provided neuroprotection in cerebral ischemia/reperfusion (I/R) injury. Regarding inhibitory system in CNS, K(+)-Cl(-)-co-transporter 2 (KCC2), a Cl(-) extruder, plays a critical role in gamma-aminobutyric acid (GABA) inhibitory effect in mature central neurons. However, the effect of propofol postconditioning on the expression of KCC2 in GABAergic interneurons is unclear. Therefore, in this article we describe the role of KCC2 in GABAergic interneurons in the ipsilateral hippocampal CA1 region of adult rats and the effects of propofol postconditioning on this region. Herein we demonstrate that propofol postconditioning (20mg/kg/h, 2h) improved rats' neurobehavioral abilities, increased the number of survival neurons, and up-regulated neuronal KCC2 expression in glutamic acid decarboxylase 67 (GAD67) expressing GABAergic interneurons in hippocampal CA1 region at 24h after I/R. In contrast, when rats were injected with the KCC2 antagonist, [(dihydroindenyl)oxy] alkanoic acid (DIOA), the neuroprotective effects induced by propofol postconditioning were reversed. Our study indicated that propofol postconditioning increased the expression of KCC2 in inhibitory GABAergic interneurons, thus providing acute neuroprotection to rats who had undergone cerebral I/R injury.

"Do not resuscitate" orders among deceased patients who received acute neurological care: an observation analysis

There were many reports about the "do not resuscitate" (DNR) order while practicing in the critical care units and conducting hospice affairs but limited in the neurological issues. This study investigated the possible flaws in the execution of the DNR order among patients who received acute neurological care in Taiwan. Over a 3-year period, we retrospectively reviewed the medical records of 77 deceased patients with neurological conditions for DNR orders. Registry and analysis works included demography, hospital courses, DNR data, and clinical usefulness of the lab and image examinations. Sixty-seven DNR orders were requested by the patients' families, and more than half were signed by the patients' children or grandchildren. The main DNR items were chest compression, cardiac defibrillation, and pacemaker use, although several DNR patients received resuscitation. The mean duration from the coding date to death was 7.6 days. Two-thirds of the patients with DNR requests remained in the intensive care unit, with a mean stay of 6.9 days. Several patients underwent regular roentgenography and blood tests on the day of their death, despite their DNR orders. Hospital courses and DNR items may be valuable information on dealing with the patients with DNR orders. The results of this study also suggest the public education about the DNR orders implemented for neurological illnesses.

Perispinal etanercept for post-stroke neurological and cognitive dysfunction: scientific rationale and current evidence

There is increasing recognition of the involvement of the immune signaling molecule, tumor necrosis factor (TNF), in the pathophysiology of stroke and chronic brain dysfunction. TNF plays an important role both in modulating synaptic function and in the pathogenesis of neuropathic pain. Etanercept is a recombinant therapeutic that neutralizes pathologic levels of TNF. Brain imaging has demonstrated chronic intracerebral microglial activation and neuroinflammation following stroke and other forms of acute brain injury. Activated microglia release TNF, which mediates neurotoxicity in the stroke penumbra. Recent observational studies have reported rapid and sustained improvement in chronic post-stroke neurological and cognitive dysfunction following perispinal administration of etanercept. The biological plausibility of these results is supported by independent evidence demonstrating reduction in cognitive dysfunction, neuropathic pain, and microglial activation following the use of etanercept, as well as multiple studies reporting improvement in stroke outcome and cognitive impairment following therapeutic strategies designed to inhibit TNF. The causal association between etanercept treatment and reduction in post-stroke disability satisfy all of the Bradford Hill Criteria: strength of the association; consistency; specificity; temporality; biological gradient; biological plausibility; coherence; experimental evidence; and analogy. Recognition that chronic microglial activation and pathologic TNF concentration are targets that may be therapeutically addressed for years following stroke and other forms of acute brain injury provides an exciting new direction for research and treatment.

Implementation of a dedicated cardiovascular and stroke unit in a crowded emergency department of a tertiary public hospital in Brazil: effect on mortality rates

BACKGROUND

Emergency department (ED) care for acute vascular diseases faces the challenge of overcrowding. A vascular unit is a specialized, protocol-oriented unit in the ED with a team trained to manage acute vascular disorders, including stroke, coronary syndromes, pulmonary embolism (PE), and aortic diseases.

OBJECTIVES

The objective was to compare case fatality rates for selected cardiovascular conditions before and after the implementation of a vascular unit.

METHODS

Patients with the selected diagnoses admitted to the ED in two different time periods, 2002 through 2005 (before unit opening) and 2007 to 2010 (after vascular unit opening), were identified by ICD-10 codes, and their electronic records were reviewed. Case fatality rates were calculated and compared for both time periods.

RESULTS

The period prior to unit implementation (2002 through 2005) included 4,164 patients, and the vascular unit period (2007 to 2010) included 6,280 patients. Overall, the case fatality rate for acute vascular conditions decreased from 9% to 7.3% with vascular unit implementation (p = 0.002). The in-hospital mortality rates for acute coronary syndrome (ACS) dropped from 6% to 3.8% (p = 0.003), and for acute PE dropped from 32.1% to 10.8% (p < 0.001). The stroke case-fatality rate did not decrease despite improvements in the quality of stroke health care indicators.

CONCLUSIONS

The vascular unit strategy has the potential to reduce overall mortality for most acute vascular conditions.

Evidence for high translational potential of mesenchymal stromal cell therapy to improve recovery from ischemic stroke

Although ischemic stroke is a major cause of morbidity and mortality, current therapies benefit only a small proportion of patients. Transplantation of mesenchymal stromal cells (MSC, also known as mesenchymal stem cells or multipotent stromal cells) has attracted attention as a regenerative therapy for numerous diseases, including stroke. Mesenchymal stromal cells may aid in reducing the long-term impact of stroke via multiple mechanisms that include induction of angiogenesis, promotion of neurogenesis, prevention of apoptosis, and immunomodulation. In this review, we discuss the clinical rationale of MSC for stroke therapy in the context of their emerging utility in other diseases, and their recent clinical approval for treatment of graft-versus-host disease. An analysis of preclinical studies examining the effects of MSC therapy after ischemic stroke indicates near-universal agreement that MSC have significant favorable effect on stroke recovery, across a range of doses and treatment time windows. These results are interpreted in the context of completed and ongoing human clinical trials, which provide support for MSC as a safe and potentially efficacious therapy for stroke recovery in humans. Finally, we consider principles of brain repair and manufacturing considerations that will be useful for effective translation of MSC from the bench to the bedside for stroke recovery.

A standardized approach to the Fugl-Meyer assessment and its implications for clinical trials

BACKGROUND

Standardizing scoring reduces variability and increases accuracy. A detailed scoring and training method for the Fugl-Meyer motor assessment (FMA) is described and assessed, and implications for clinical trials considered.

METHODS

A standardized FMA scoring approach and training materials were assembled, including a manual, scoring sheets, and instructional video plus patient videos. Performance of this approach was evaluated for the upper extremity portion.

RESULTS

Inter- and intrarater reliability in 31 patients were excellent (intraclass correlation coefficient = 0.98-0.99), validity was excellent (r = 0.74-0.93, P < .0001), and minimal detectable change was low (3.2 points). Training required 1.5 hours and significantly reduced error and variance among 50 students, with arm FMA scores deviating from the answer key by 3.8 ± 6.2 points pretraining versus 0.9 ± 4.9 points posttraining. The current approach was implemented without incident into training for a phase II trial. Among 66 patients treated with robotic therapy, change in FMA was smaller (P ≤ .01) at the high and low ends of baseline FMA scores.

CONCLUSIONS

Training with the current method improved accuracy, and reduced variance, of FMA scoring; the 20% FMA variance reduction with training would decrease sample size requirements from 137 to 88 in a theoretical trial aiming to detect a 7-point FMA difference. Minimal detectable change was much smaller than FMA minimal clinically important difference. The variation in FMA gains in relation to baseline FMA suggests that future trials consider a sliding outcome approach when FMA is an outcome measure. The current training approach may be useful for assessing motor outcomes in restorative stroke trials.

Repetitive transcranial magnetic stimulation for improving function after stroke

BACKGROUND

It had been assumed that suppressing the undamaged contralesional motor cortex by repetitive low-frequency transcranial magnetic stimulation (rTMS) or increasing the excitability of the damaged hemisphere cortex by high-frequency rTMS will promote function recovery after stroke.

OBJECTIVES

To assess the efficacy and safety of rTMS for improving function in people with stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (April 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 4), the Chinese Stroke Trials Register (April 2012), MEDLINE (1950 to May 2012), EMBASE (1980 to May 2012), Science Citation Index (1981 to April 2012), Conference Proceedings Citation Index-Science (1990 to April 2012), CINAHL (1982 to May 2012), AMED (1985 to May 2012), PEDro (April 2012), REHABDATA (April 2012) and CIRRIE Database of International Rehabilitation Research (April 2012). In addition, we searched five Chinese databases, ongoing trials registers and relevant reference lists.

SELECTION CRITERIA

We included randomised controlled trials comparing rTMS therapy with sham therapy or no therapy. We excluded trials that reported only laboratory parameters.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, assessed trial quality and extracted the data. We resolved disagreements by discussion.

MAIN RESULTS

We included 19 trials involving a total of 588 participants in this review. Two heterogenous trials with a total of 183 participants showed that rTMS treatment was not associated with a significant increase in the Barthel Index score (mean difference (MD) 15.92, 95% CI -2.11 to 33.95). Four trials with a total of 73 participants were not found to have a statistically significant effect on motor function (standardised mean difference (SMD) 0.51, 95% CI -0.99 to 2.01). Subgroup analyses of different stimulation frequencies or duration of illness also showed no significant difference. Few mild adverse events were observed in the rTMS groups, with the most common events being transient or mild headaches (2.4%, 8/327) and local discomfort at the site of the stimulation.

AUTHORS' CONCLUSIONS

Current evidence does not support the routine use of rTMS for the treatment of stroke. Further trials with larger sample sizes are needed to determine a suitable rTMS protocol and the long-term functional outcome.

Past, Present, and Future of Stroke in Middle-Income Countries: The Brazilian Experience

Background

Stroke is one of the major public health challenges in middle-income countries. Brazil is the world's sixth largest economy but was clearly behind the milestones in the fight against stroke, which is the leading cause of death and disability in the country. Nevertheless, many initiatives are now reshaping stroke prevention, care, and rehabilitation in the country.

Aims

The present article discusses the evolution of stroke care in Brazil over the last decade.

Methods

We describe the main characteristics of stroke care before 2008; a pilot study in a Southern Brazilian city between 2008 and 2010, the Brazilian Stroke Project initiative; and the 2012 National Stroke Policy Act.

Results

The National Stroke Project was followed by a major increased on the number of stroke center in the country. The key elements of the 2012 National Stroke Policy Act included: definition of the requirements and levels of stroke centers; improved reimbursement for stroke care; promotion of stroke telemedicine; definition of the Line of Stroke Care (to integrate available resources and other health programs); increased funding for stroke rehabilitation; funding for training of healthcare professionals and initiatives to increase awareness about stroke within the population.

Conclusions

The evolution of stroke care in Brazil over the last decade is a pathway that exemplifies the challenges that middle-income countries have to face in order to improve stroke prevention, treatment and rehabilitation. The reported Brazilian experience can be extrapolated to understand the past, present, and future of stroke care in middle-income countries.